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Data Across the Continuum of Care
Nursing Symposium, February 11, 2019
Becky Fox, MSN, RN-BC, Chief Nursing Informatics Officer
Stephanie H. McIntyre, MBA, RN-BC, CHPQ, Assistant Vice President, Information & Analytics Services
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Becky Guess Fox and Stephanie H. McIntyre have no real or
apparent conflicts of interest to report.
Conflict of Interest
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Data challenges across the continuum
Current healthcare landscape and challenges in US
How has data landscape has changed?
Data across the continuum drives value
Alignment and practical applications
Data challenges
Define how data can be used to change individual behavior
Stakeholders
Comprehensive Assessment
Examples
Suggested Steps
Agenda
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Discuss how nurse informaticists can ensure proper systems translation and
communication
Definition
How?
Identify essential organizational players and their vital roles in transitional care
Key players
Thinking differently
Provide key takeaways in identifying source data for specific transitions of
care
Data sources
Care Management across the continuum
Lessons learned from our organization
Agenda (continued)
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Identify potential challenges with data flow across the continuum
Define ways data can be used to change individual behavior
Discuss how nurse informaticists can ensure proper systems
translation and communication
Identify essential organizational players and their vital roles in
transitional care
Provide key takeaways in identifying source data for specific
transitions of care
Learning Objectives
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Data challenges across the
continuum
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Healthcare Challenges in the US
250,000 deaths per year due to medical error
Comprises 18% of GDP . . . and increasing
US quality ranks low when compared to other developed
countries
$3.06 trillion spent in 2014*; growing at rate of 5.8 percent**
“Waste” = $765 Billion (30% of total):
$210B unnecessary services
$190B excessive administrative costs
$130B inefficiently delivered services
$105B prices too high
$75B fraud
$55B missed prevention opportunities
Over 54 Million Enrolled in Medicare^; 78 Million by 2030 (last
year of baby boomer eligibility)
Sources: *Office of the Actuary at the Centers for Medicare and Medicaid Services; **National Health Expenditure Projections, CMS; ^Kaiser Family Foundation;
^^Facts on Medicare Spending, Kaiser Family Foundation; ^^^2013 Actuarial Report, Department of Health and Human Services
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How has the data landscape changed?
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Data Across the Continuum
LONGITUDINAL PERFORMANCE MANAGEMENT
(Population Health Management)
Payers
Physician
Orgs
CINs
ACOs
Employers
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Data across the continuum
Connect the
continuum
Empower patients,
care teams,
and organizations
Facilitate
knowledge-driven
care
and continuous
learning
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Outpatien
t
Ambulatory
Home
Health
Acute
Care
SNF
Lab
Patient
Epic
Cerner EMR1 EMR 2 EMR 3
EMR 4 EMR 5
Data Repository & Master Patient Index
Population Health Platform
Care
Transitions
Care
Gaps/Healt
h
Disparities
Risk
Stratificatio
n
Chronic Care
Management
Wellness
Support
Alignment
of Social
Services
Disease
Managemen
t
ED
Utilization
Need to focus alignment of data that will enable us to:
Assist in strategic decision-making
Risk stratify patients and populations
Analyze potential opportunities for care improvement and cost reduction
Assess gaps in care delivered
Alignment of Data and Information
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What is the practical application?
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Interoperability
Variability in
systems
Expense to
aggregate and
normalize
Timeliness
Security and
Privacy
Risk
Data Use
Agreements
May limit access
Applicability
Turning data into
actionable
information
Embedding
meaningful data
into workflow
Emerging patient
engagement
technologies
Data Quality
Provider
Attribution
Data Validation
Patient
Generated Data
Data Governance
Culture
Perfect vs Good
Overengineering
Crawl before
Walking
Data Challenges
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Using Data to Change Behavior
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Stakeholders and things that influence
All stakeholders benefit
when patients reach their
optimum level of wellness,
self-care management, and
functional capability. These
stakeholders include the
patients, their support
systems, and the healthcare
delivery system providers of
care, the employers, and
payors.
Ability to
Self-
Care
Developmental
State
Resource
availability
Health State
Family system
factors
Sociocultural
orientation
Age
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Comprehensive Assessment
Medication Adherence Assessment and Evaluation
Environment, Resources and Services
Financial Health
Fitness Habits
DME/Functional Evaluation
Skilled Services Evaluation
Systems Evaluation
Barriers to Care
PHQ-9 and Referral to BHI if warranted
Readiness to Change
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Summary Diabetic Cohort Study
n=2599, 30% reduction in overall visits and 28% reduction
in overall billed charges for a total of $6,288,550 reduction
Pre and Post 180 days enrollment
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Amb. Care Mgmt: Hgb A1C (n=961)
Compare lab values in
patient cohort 1 month prior
to ACM program enrollment
and 1 month prior to
program graduation date
Average 1
month prior to
program
enrollment:
Average
HbA1C: 9.50
Median HbA1C:
9.10
Average 1
month prior to
program
graduation:
Average
HbA1C: 7.04
Median HbA1C:
7.00
Statistically significant reduction in HbA1C is found pre and
post ACM program enrollment at group Level
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ED High Utilizer Cohort
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Ability to view
preventable ED visit
volume by hospital
Key metrics
including number of
visits and net
margin by age
bands
Preventable ED visit
detail by practice
attribution
Filter visit volume by
condition
Building Visibility
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Building Visibility
Filters for
preventable ED
category and
primary diagnosis
Ability to view
practice-level
volumes of
preventable ED
visits
Graphic illustration
of visit type by time
of day
Patient density
analysis by distance
to nearest ED
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Use Data to Build Patient Population
List
Identifying Markers in the Data
30 or more visits within one
EMR
158 patients identified
7054 visits
$22,022,370 charges
Payor Mix
2003 Self Pay
2084 Medicaid
918 Managed Care
464 Medicare Advantage
1560 Medicare
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Craft Tactics
Game Plan
Contact patients and enroll
within appropriate care
management programs
Identify barriers to care
Enroll in applicable programs
(BH, substance abuse, housing,
etc. )
Keep ongoing contact
1
st
Data, YTD Feb
Monthly roll call
March 24th
Goal: Reduce Billed Charges
50%
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Work as a Team
Running Man Intervention
Data Analysis
Who
Payor
Diagnosis
Time of Day
Then
Patient Interview
Structured data
collection
interventions
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Work as a Team
ED Bouncing Ball Icon
The icon will display on the FirstNet tracking
board in the Events column as soon as the
patient is registered to the ED.
At the same time, a page/email will also be sent
to the CCM distribution list for each facility.
The logic behind the icon and page is looking for
at least one Inpatient visit that was discharged
within 30 days of the current ED visit’s arrival
time.
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See Results
Based on the incredible work by the IAS Team and the Care
Management Team, there has been a 46% overall reduction in ED
admissions in three months.
Existing resources at CHS are being leveraged to help this group
of patients. The Transitions Clinic is one example of how
repurposing could keep the ED admissions down and help us hit
our system goals.
Systems are now in place to catch these patients that may have
fallen through the cracks previously due to bouncing around
locations, lower charges, lower numbers of inpatient admissions,
or lack of complex chronic or rising risk data screening.
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Nurse Informaticists can ensure
proper translation and
communication
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“The specialty that integrates nursing science with multiple
information management and analytical sciences to identify,
define, manage, and communicate data, information, knowledge,
and wisdom in nursing practice.
NI supports nurses, consumers, patients, the interprofessional
healthcare team, and other stakeholders in their decision-making
in all roles and settings to achieve desired outcomes.
This support is accomplished through the use of information
structures, information processes, and information technology.”
https://www.himss.org/what-nursing-informatics
Nursing Informaticists
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Validating data quality from external sources and ensure correct matching
Understand current and future state workflow
Operationalize how clinicians will use
Support teams with change management through the transition
Leverage Clinical Decision Support
At the right time
Meaningful alert
Breakdown the data
Example
Understand business, financial, strategic impact to the organization
Communicating differently
How can Nursing Informaticists
contribute?
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Registry Development
Understand clinical processes
Identify care gaps/workflow challenge
Validate populations and measures
Support providers around attribution
Example
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Essential Organizational
Players and their Vital
Roles in Transitional Care
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Everyone plays (or will play) a role in Population Health!
Key will be the requirement of a cultural shift and not “the way
we’ve always done it”
Requires understanding of the bigger picture and the bigger
contribution
Essential Organization Players
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Think di erently
ff
Sharing the EMR or view (not just sending pt with a paper packet)
Extending your care coordination technologies (Seeing care that
occurs outside of your organizational walls, e.g. Patient Ping)
Creating bi-directional feedback loops (Connecting with outside
resources, e.g.Connecting services for a patient with Aunt Bertha)
Ensuring a feedback loop
Connecting clinical leaders at both locations
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Care Management / Home Health (including from the payors) that
can assist in smoothing the processes has to extend beyond the
traditional players
E.g. aunt Bertha examples – faith based, don’t just be stuck
in nurse in acute and nurse in SNF
Social determinants of health play a part in this and
understanding communities and the societal support
Their Vital Roles in Transitional Care
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Alignment of Assets and Stakeholders
Physicians &
Providers
Post Acute
Patients
Leaders &
Associates
Acute Care
Facilities
Payers &
Employers
Ambulatory
We need to integrate all aspects of care to improve quality,
reduce costs and improve outcomes for the patients we serve.
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Key Takeaways in
Identifying Source Data for
Specific Transitions of Care
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Data across the continuum
Connect the
continuum
Empower
patients, care
teams,
and organizations
Facilitate
knowledge-driven
care
and continuous
learning
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And many more…
Faith based organizations
Community resource organizations
Patient self-management solutions
Other potential business / health/ pharma / vendors will continue
to morph in this space
BE PREPARED to innovate or think outside the box!
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Cross Continuum Care Management
Multi
-Disciplinary Team
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Highest ED utilizer in Atrium System for at least past 3 years
(over 1500 service/visits within Atrium Health
Jan April 2018 (120 calendar days), Joe has had 104 ED visits
Other 16 days spent inpatient or observation
ED, Inpatient, and Observation Facility Charges from 2015-2017
are over: $1,570,900
YTD 2018 charges are $366,125
Joe’s Story
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Meet Joe
Joe comes to ED because of an
overwhelming fear he will die of
numerous different medical
ailments.
He lives in a car and moves
between parking decks (CMC-
Main and Union) to have quick
access to the ED.
Joe notes that the only thing that
helps him feel normal is coming to
the ED daily and having a doctor
reassure him that he will be fine.
PTSD
Overwhelming anxiety
Hypochondriasis
Major Depressive
Disorder
Alcohol Use Disorder
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New concept: Population Health version of Medical Ground Rounds
Launched on May 18, 2018
Multi-Disciplinary team meets monthly and present complex unresolved cases
Through critical thinking and collaboration an action plan is designed
Focused efforts to solve for self-imposed constraints and for absence of process
How do we know about Joe?
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What did we do for Joe?
Care Team Meeting
PARC Staffing
Scheduled
Obtained Housing
(and sold his car)
Daily Behavioral
Health Therapy
Assigned to
Primary Care
Provider
Cell Phone, Food
Stamps,
Medicaid, SSI
Daily Community
Paramedicine
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Update on Joe
Yeah things are moving in the right
direction. Finely, I feel like a human again.
Only 3 ED visits since Joe secured housing on June 12
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Understand your process drivers for defining the data you need
and don’t try to “boil the ocean”
Leverage informaticists in the data aggregation and validation
processes
Consider what each stakeholder needs to know and that the
information you share is actionable, or connected to automatic
actions
Think differently
Consider the patient holistically
Share data to support the patient’s specific needs
Lessons Learned and Key Take Aways
from Our Organization
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Contact information:
Becky G. Fox, MSN, RN-BC
Chief Nursing Informatics Officer
Becky.fox@atriumhealth.org
Linkedin: Becky Fox
Stephanie H. McIntyre, MBA, RN-BC, CRHQ
Assistant Vice President, Information and Analytics Services
Stephanie.mcintyre@atriumhealth.org
Linkedin: Stephanie H. McIntyre
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Questions